After Hours Medical Ward Duties in a Teaching Hospital

Article excerpt

Abstract

In many Australian hospitals a medical officer is available for urgent review of inpatients outside normal working hours. Current practice in nurse-initiated requests for medical officer involvement out of hours may adversely affect patient outcome as well as medical and nursing resource use at these times.

Of 10523 nurse-initiated requests for out-of-hours review recorded by medical officers at our hospital in 2002-2003, the most frequent reasons for the requests were medication review, IV fluid orders, IV resite, venesection, and pathology review, none of which are related to acute changes in clinical condition. Requests for routine review of medication and fluid orders were found to be rarely essential and often inappropriate. Medical officer activity was highest before midnight and least after midnight, suggesting most requests are fulfilled in the evening.

Several strategies to reduce inappropriate out-ofhours requests were identified. Routine tasks could be completed by primary treating unit staff before going off duty. IV cannulation and venesection may be performed by appropriately trained phlebotomists or skilled advanced practice nursing staff. Meticulous ordering of 'as required' analgesia and night sedation would reduce unnecessary requests. Clinical protocols for nurse-initiated adjustment of drugs with variable dosing may also decrease inefficiencies. This would leave the ward cover medical officers more available for their primary function of urgent patient review.

Aust Health Rev 2005: 29(1): 37-42

INITIAL OUT-OF-HOURS MEDICAL CARE of inpatients in Australian hospitals is often undertaken by ward cover medical officers (MOs) without direct supervision. They often have little or no direct knowledge of the patients they are expected to care for on an ad-hoc basis, leading to suboptimal clinical decisions being made.

Requests for urgent medical review of inpatients in Australian hospitals out of ordinary working hours are communicated by ward nurses to the ward cover medical officer (MO) on an as-required basis. Although on-call registrars are available to provide advice or to attend in emergency situations, this cover is often neither immediate nor readily accessible. This process has developed without an evidence base and may not constitute best practice.1 There is scarce data regarding urgent medical review out of hours or the suitability of junior medical officers to be delivering this care within acute care hospitals. Out-of-hours mpatient medical care requires baseline study with emphasis on quality of care improvement and appropriate and adequate medical staffing.2

The ward cover MO is often disrupted during patient assessments by calls for non-urgent or routine tasks that should have been fulfilled during regular working hours. Such requests are medically inappropriate in the context of a busy urgent out-of-hours review service with limited medical staff resources.

Lack of organised teaching and difficulty in contacting covering registrars for advice or assistance reduces work satisfaction for ward cover MOs. Upreferral consultation processes may not be clearly delineated. Evening and overnight shifts cause deleterious physical and psychological effects even in the absence of sleep deprivation.3 During busy periods, meal and rest breaks are missed.4

While at times busy, chaotic and stressful, outof-hours work allows relatively independent practice and is clinically challenging. Examination of the after-hours request process, from a ward nurse communicating a request to its fulfilment by the medical officer, may help identify inappropriate requests, omissions in routine daytime care and other process difficulties.

Methods

The Mater Adult Public Hospital is a metropolitan adult teaching hospital with 200 beds, comprising medical, surgical, orthopaedic, gynaecology, cancer services, coronary care and intensive care units. …